ethical vilemmas and practice or.iented...

Ethical Vilemmas and Practice ... Or.iented Questions

The fundamental value of studying and understanding ethical thought is not that we thereby have definitive guides to moral ~onduct. Rather the value lies in becoming aware of the moral optIons available to ~s of the general paradigm within which moral inquiry can take plac: as concrete human beings grapple with real-lif~ issues. Individual moral choices are frequently not between ObVIOUS right and wrong, good and bad, but between act.ions and values ~hat contain elements of both. The challenge, then, IS not so much flllding an ethical standard to use but applying a defensible standard in specific instances.

-Barry (1982, p. 89)

W ork for health is a moral endeavor," exclaims Seedhouse (1988). But it is not, he clarifies, "a moral endeavor in the

sense of a crusade" (p. xiv). Yet messages of public health communication interventions often carry connotations of righteousness and virtue. Their rhetoric is often composed of images of "wars" and "attacks" on diseases or substances, which may vilify particular behaviors, sanctify others, or inadvertently stigmatize certain members of society. Furthermore, an intervention's goal to promote people's health may infringe on their privacy, personal preferences,

172

Ethical Dilemmas, Practice- Oriented Questions 173

or autonomous decisions (Levin, 1987). The design and implementation of public health campaigns thus invariably raises ethical dilemmas, dilemmas that cannot be neatly solved by applying specific ethical principles. "Ethics," Seedhouse explains, "is always a question of degree, a question of deliberating about which interventions in other people's lives will produce the highest possible degree of morality" (p. xv). Because people hold different values and beliefs, he continues, there are no clear-cut solutions to what we may consider a good intervention in someone else's life. Whatever solutions are adopted, they depend in one way or another on values: "Even advice about diet and exercise is never based wholly on fact. At some stage a value judgment of some kind will be made" (p. xv). Seedhouse's words echo the main thesis of this book: Value judgments are performed in all facets of the intervention. Inherently, they involve ethical considerations! and raise ethical dilemmas. The latter are often invisible, especially when it is taken for granted that interventions inherently aim to promote the health of the public.

Health care is a context replete with ethical issues. Medical care providers are often acutely aware of ethical dilemmas in their daily practice and the practice of medicine in general. Modern technologies that allow for procedures to prolong people's lives also force people to make painful decisions: when to use sophisticated technologies and when to refrain from using them, and who should decide? Who should be chosen to benefit when resources are scarce? Public health communication interventions, although they may not involve immediate life-and-death issues, are also rife with ethical concerns similar to those raised in biomedical contexts.2 The interventionists also face the dilemmas of when to apply the most effective communication techniques and when to refrain from using them, how to achieve the most effective persuasive message that is ethically derived and delivered (Ratzan, 1994), and what resources should be allocated to this effort. Although they presumably aim to promote the good of intended populations (Rogers, 1994), benefits from their outcomes may not be equally distributed. In addition, because more and more public health interventions adopt sophisticated social-marketing techniques, the enhanced ability to persuade raises concerns regarding the extent to which they may engage in unethical manipulation (Faden, 1987): "[A] preventive health campaign is a marketing effort, subject to all the risks of motivational marketing-hyperbole, demagoguery, or praying upon fears and prejudices" (Goodman & Goodman, 1986, p. 29);

174 PUBLIC HEALTH COMMUNICATION INTERVENTIONS

The 14 ethical dilemmas presented in this chapter address four major areas: (a) the use of particular intervention strategies, (b) the possibility of causing inadvertent harm, (c) issues related to power and control, and (d) issues related to social values. The chapter concludes with a series of practice-oriented questions presented in summary tables. Brown and Singhal's (1990) thought-provoking discussion of ethical dilemmas in the use of television programs to promote social issues inspired the development of this framework and provided some ofits core constructs.3 Brown and Singhal underscore dilemmas regarding the content of messages and the promotion of equality among viewers, here included in the area of intervention strategies; dilemmas related to unintended effects, here also referred to as unintended effects but expanded to include a discussion of social values and power and control; and dilemmas related to the use of the media for development, here incorporated

in the discussion of strategies.4 The ethical concerns raised in this chapter also draw on Forester's (1989, 1993) adaptation of Habermas's (1979) work in the context of planning. Because public health communication interventions are clearly a communicative process, their potential impact raises concerns regarding claims made by the intervention that may influence people to ad~pt ~ealt~ier behaviors but may also result in what can be viewed as commumcatIve dIStortions. These may influence the way people think and interpret the social phenomenon in ways that misrepresent important social processes that actually take place or that may serve the interests of dominant soci~ gro~ps.s

Four precepts are singled out for discussion: truth, consent, IdentIty, and

framing.

Truth: The truthfulness of the messages can affect people's beliefs, for ex

ample, about what illness is, what activities are health promoting, who is responsible for the health problem, and how important it is to attend t~ the. problem as it has been defined by the intervention, as well as belIefs In the effectiveness of the recommendations. This can be related to ethical concerns about intervention strategies, including their persuasive messages, and regard-

ing values or cultural reproduction.

Consent: The legitimacy of the norms invoked may affect people's willingness to consent to presumed authority and can be related to ethical concerns

about power and control.

Ethical Dilemmas, Practice-Oriented Questions 175

Identity: People's senses of identity may be influenced as a result of exposure to certain types of messages-for example, those that may label them as deviant or bad-or the development of particular relationships in the health-promotion context. These activities can be related to ethical concerns about inadvertent outcomes.

Framing: The selection or prioritization of issues may affect people's comprehension or perceptions of priorities and can be related to ethical concerns associated with social values and ideologies. For example, one way of framing the issue is that certain health conditions should be pursued mainly through education rather than through institutional or structural changes.

The bioethics literature discussed in the previous chapters also provides us with constructs to examine ethical concerns. These include ethical principles of avoiding doing harm, respect for personal autonomy and freedom to make one's own decisions, utility, concern for justice and fairness in distribution of resources, and adherence to the obligation to care for those with whom one has a special relationship or toward whom one has particular comminnents. The first eight dilemmas apply what Duncan and Cribb (1996) describe as analytic health care ethics, which rely on ethical principles. The last six dilemmas raise more structural-level issues and are concerned with how public health communication interventions may (inadvertently) serve to reproduce power relations or institutional systems or practices.

DILEMMAS CONCERNIN(f CAMPAI(fN 5TRATE(flES

1. The Persuasion Dilemma

The persuasion dilemma incorporates two concerns, which represent the flip side of each. The first raises concerns regarding the persuasive capacities that may infringe on people's autonomy. The second is concerned with whether the intervention fulfills the ethical imperative of doing the utmost to promote the good of its intended audience by applying the most persuasive tactics to help people adopt its recommended health-promoting messages.

To what extent is it justified to use persuasive strategies to reach the intended health-promoting effects of the intervention?

~ . r ;1


The dilemma regarding the ethics of the manipulative potential of persua

sion is often shared, though less often acknowledged, by many if not ~l public

mmunication interventions (Witte, 1994). Because public health 1Oterven-co b h . tions' goals typically aim to influence target populations' belief~ or e a:lOrs, perspasive and social-marketing strategies are often e~ployed .. The ultImate

oal of these intervention strategies, as Witte (1994) po1Ots out, IS to get people

;0 practice what the interventionists believe are health-promotin~ behavi~rs. Efforts to.do good and convince the public of the benefits of adoptIng p~cular behaviors or of avoiding others thus often include persuasive strategies to arouse anxieties or fears and facilitate persuasion. Witte (1994) maintains ~at public health communication researchers and practitioners are adept at usmg

persuasive strategies (e.g., how much and what type of informati~n to us.e about a certain topic, how to order it) to manipulate people's ~ercep~ons. T~s raises concerns regarding the use of manipulative or persuasive tacncs, w~ch by definition infringe on individuals' rights for aut~nomy or self~determ1Oation. Similarly, it raises concerns regarding paternalism or the bebef that ce~tain experts or professionals know what is best for particular members ~f SO~Iety or the public as a whole. Wh~reas these concerns tra~tionally are ralsed 10

the practitioner-patient context (e.g., Bok, 1978; Childress, 1~82: V~atch, 1980), they are also highly relevant in the public health commurucatlon mtervention context because such interventions are purposeful efforts to get peo~le to adopt health-related practices perceived as beneficial to them or as helpmg them avoid potential harm (Beauchamp, 1988; Campbell, 1990; Faden, 1987; Pinet, 1987; Doxiadis, 1987). According to the principle o~ re~pectfor a~to~omy, health promoters should honor the self-respect and dlgruty of each mdl-

vidual as an autonomous, free actor. The use of persuasive appeals also raises concerns regarding the extent to

which such appeals distort or manipulate information (as elaborated by F~rester, 1993) or the extent to which such maIJipulative strategies can under~e the development of connectedness, responsiveness, and a s~nse of gen~m.e care which are important components in an ethic of care (Baler, 1993). SIIDl

lar1;' the use of persuasion raises concerns regarding legitimacy an~ control: Persuasive messages that aim to affect attitude change and the adoptlon of the recommended behaviors succeed essentially by controlling people's percep

tions and thus limiting their choices from a wider range of optio~s (Fad~n ~ Faden, 1982). As Salmon (1989) reminds us, "At the center of thiS conflict IS the fundamental tension between social control and individual freedoms.

Ethical Dilemmas. Practice-Oriented Questions 177

Social-marketing efforts, by definition, employ mechanisms of social control" (p. 19).7 Inherent in the design and implementation of public health communication interventions, therefore, is a tension between competing values of autonomy and of doing good.

To what extent should health promoters model their persuasive messages on advertising or marketingtechniques-even when these tactics are viewed as the most promising venues for affecting attitudes and behaviors?8 Highly persuasive messages that use emotionally charged fear-raising and guilt-raising appeals can be justified by communicators on the basis of utility, especially if they draw on research that used target audience members' perceptions.9 When audience members are asked what types of messages would work for them or would help modify people's behavior and get them to adopt the recommended activity, respondents often suggest that interventionists should use scare tactics or fear appeals. to But does this mean that these messages are the optimal and ethical ones? The use of persuasive strategies in the context of advertising has been criticized as being potentially unethical because they may use manipulative, misleading, or deceptive messages: concerns compounded because advertising campaigns tend to target populations particularly vulnerable to their messages. This critique can be applied to public communication campaigns as well (Pollay, 1989). The American Cancer Society, according to critics, used inflated statistics in its efforts to persuade women to engage in preventive cancer detection behaviors. The persuasive messages they used may have unduly terrified some women, argue the critics. The American Cancer Society justified its use ofthese statistics by saying they believed they could serve as effective means to get women to adopt preventive measures and seek early detection (Blakeslee, 1992). In contrast, Salmon and Kroger (1992) report that practitioners in the U.S. National AIDS Information and Education Programs, a government-sponsored health agency, decided to give prominence to the principle of what they considered do no harm and to avoid messages that could potentially frighten target populations. 11 A different approach was revealed in a surprising announcement made by an advisory panel to the Natio~al Cancer Institute. This panel recommended that the Institute should only provide scientific data and should not engage in persuasive appeals to get women to get mammo

grams at a particular age. Instead, it suggested the Institute should let the public draw its own conclusions (Kolata, 1993). This approach raises ethical concerns as well: To what extent are health promoters obligated to use persuasive strategies if they believe these strategies to be the most effective method to achieve


the goals of the campaign and to fulfill their mandate of maximizing the.healt~ of the target population? This concern relates to the second persuasIOn dIlemma: the extent to which the intervention employs the most effective tactics to deliver messages that will help people or organizations adopt the recommendation of the intervention addresses several key concerns. The first is, to what extent do the interventionists have the knowledge, expertise, and resources to develop appropriate messages, and second, what are the best strategies to develop such messages: Do the interventionists have the resour~es to develop messages and strategies that can indeed be effective? Should the mterventionists employ current marketing techniques and work mainly with professionals or adopt approaches in which intended audience members act as

equal partners in message development?

2. The Coercion Dilemma

Is it justified to promote restrictive regulations orpolicies regarding individ

uals, behavior to achieve the health goals of the campaign?

The use of coercion poses the same types of concerns raised regarding per

suasion:

Questions about the morality of coercion, manipulation, deception, persuasion, and other methods of inducing change typically involve a conflict between the values of individual freedom and self-determination, on one hand, and such values as social welfare, economic progress, or equal opportunity on the other hand.

(Warwick & Kelman, 1973, p. 380)

One of the arguments in support of strategies that restrict or regulate peo

ple's or organizations' activities or control their environment is that they are relatively effective in promoting the desired health-related outcome.12 As McKinlay (1975) states, "One stroke of effective health legisla~on is equal.to many separate health intervention endeavors and the cumulative efforts of mnumerable health workers over long periods of time" (p. 13). For example, legislation for smoke-free environments is viewed as a strategy that can have a larger impact on smoking behavior of large numbers of people than educational programs (Glantz, 1996). Similarly, engineering-type solutions can also be seen as relatively effective (Schwartz, Goodman, & Steckler, 1995). Redesigning roadways and improving the safety engineering of cars have been


shown to significantly reduce automobile accidents and fatalities, independent of the actions of the drivers. Similarly, changing lunch menus of schools or work organizations has been shown to affect the food consumption of the students or workers in these organizations (Ellison et al., 1989; Glanz & Mullis, 1988). On a more macro level, regulation of the food industry and restrictions on food production could increase the likelihood that consumers would buy foods relatively low in saturated fats and free of contaminants, making their food consumption healthier. This type of reasoning can be seen as applying the' principle of utility or the obligation to maximize the greatest utility from the health promotion efforts to the greatest number of people (Hiller, 1987). However, it raises concerns regarding the ethical principle of individual autonomy or the right people have not to be restricted in their personal choices. Notwithstanding concerns for autonomy, in addition to its potential utility, an important justification for the use of restrictive strategies is based on the assumption that individuals' choices are in fact not autonomous but influenced by powerful social and market circumstances. People in our society, explain proponents of regulative strategies, are surrounded by persuasive antihealth messages and antihealth environments, and therefore, they do not freely choose unhealthy behaviors. This justifies the use of prohealth persuasive or coercive strategies or of policies to restrict the freedom of groups, including marketers of certain products (Pinet, 1987). One example of this approach is efforts to restrict the placement of cigarette vending machines, a strategy shown as effective in curtailing cigarette sales, especially among children and adolescents (Feighery et aI., 1991). Another example of policies to promote health through restrictions on public access to a product is the Japanese government's ban of birth control pillS,13 which was adopted in part to promote the use of condoms and justified partially by being perceived as a way to curb the spread of HIV infection (Jitsukawa & Djerassi, 1994; Weisman, 1992).

Coercive approaches are fraught with ethical concerns, including the infringement on individuals' free choice and free-marketplace enterprise, which are particularly prominent values in Western society. Market autonomy, according to its proponents, is the optimal method for the distribution of goods and for balancing economic contribution and economic rewards. Restricting it would impose restrictions on choices to individuals and thus impinge on individual autonomy as well (Garret et al., 1989). But the marketplace, maintain critics, does not provide free choices for individuals or communities because other socioeconomic factors influence the distribution of goods, services, and


wealth (Beauchamp, 1987; Bellah et al., 1985, 1991). Dan Beauchamp (1987) argues that, relative to other intervention approaches, enforcement strategies enhance the public good on the societal level while minimally intruding on individuals because they mainly place controls on the marketplace. Instead of plaoing restrictions on personal liberty, he explains, by controlling potential

hazards through a collective action and sharing the burdens of protection, intervention policies can foster a sense of community responsibility for the welfare of its members. Even if we adopt this perspective, we are still left with questions regarding the extent to which individuals should be restricted from engaging in practices perceived as risky from a health-promotion perspective but nevertheless desired by some. What are the boundaries? When should society intervene? Does society have an obligation to intervene when the individual's well-being is threatened by his or her own action (pinet, 1987; Wikler, 1987), or should it intervene only when a person presents a danger to others, as in the case of communicable diseases?

Regulative strategies may also be applied to the channels that disseminate intervention messages. Because broadcast media, although they may be considered a public good, are licensed to commercial or not-for-profit organizations, does this imply that interventions should be able to use these media as dissemination channels? Or more specifically, should commercial media be regulated to support messages of health interventions (Packer & Kauffman, 1990), or should the interventions pay for the broadcasting of their ads through the use of excise taxes?14

3. The Reliability Dilemma

Are the recommendations proffered by the public health communication

intervention accurate and reliable? Should the interventionists disseminate what they believe is the best information they currently have, even if it may prove to be inaccurate?

To what extent are the recommendations proffered by the intervention based on reliable and accurate information? Inconsistency and inaccuracies were found in the information given to callers responding to public health

communication interventions and provided by telephone hot lines among 33 agencies that served as part of an AIDS intervention (Baxter & Gluckman, 1994). People were not getting information that was reliable and consistent


with current guidelines. The situation may be further complicated when there are no consistent or agreed-on guidelines, as when recommendations based on cert~ sc~~ntific st~dies may be refuted by others (Payer, 1993). For example, the rehablhty of eVidence regarding certain recommendations about salt, cholesterol, or dietary fiber consumption is disputed by some experts who either reach different conclusions regarding their preventive capacities or argue that one cannot generalize from large-scale population studies to individuals (Marshall, 1995; Riis, 1990). Do we need, therefore, to wait for what would be considered more reliable scientific information? But this, as Riis suggests, "could lead to a kind of defeatism in which any initiative could be postponed because 'we still do not know enough' " (p. 189).

The reliability dilemma becomes even more complex because of the observation that people-even when provided with in-depth information-may feel they know too little to make an informed choice, even when they actually know more than they did before. Providing people with more information, as illustrated in studies from the risk perception literature, may result in less confidence in the information and consequently in diminishing people's abilities to make informed choices (Hughes & Brecht, 1975). Should public health communication interventions therefore provide a great amount of information but risk saturating people with an overload of messages? Should they risk making people feel they are unable to resolve the contradictions?15 Or should the intervention provide the intended public with less detailed information to avoid confusion or so-called information overload? But then, how would the intervention serve to repudiate competing misconceptions and misinforma

tion (for example, those presented in the media) that the interventionists believe mislead the public and should be refuted?

A second dilemma associated with reliability concerns language style. Some fear that if reco~endations are stated in tentative language, they may be confusing or not effective (Barr, Waring, & Warshaw, 1992; Kolata, 1995; Miller, 1990). On the other hand, if recommendations are made using very strong language and leave no room for doubt, some fear they may be inaccurate or may backfire. "With the proliferation of guidelines and advice," commented a physician, "we are grotesquely overselling to the American people. The danger of that is that they will not believe the stuff we have that's documented" (Kolata, 1995, p. e12). Providing more health information is not necessarily health promoting and may, in fact, bring opposite outcomes: a public on one hand saturated with health messages and on the other, confused and

:1


distrusting. A marketing consultant suggests that we can end up with people who are distrustful of the health information they hear and "throwing up their hands and eating everything they want in quantity"-with a vengeance (Dullea, 1989, p. 72). This dilemma is illustrated in the case of the controversial acIrvice provided by an advisory panel to the National Cancer Institute in 1993. To avoid waiting for a definitive scientific prescription and in light of conflicting views of medical experts, the panel had recommended that the Institute should only disseminate scientific data to the public but not engage in persuasive appeals to get women to get mammograms at a certain age. Some of its members suggested that they just tell people what the state of the art is, rather than offer specific recommendations (Kolata, 1993). The Institute, after adopting the recommendation, found that this approach could backfire, when that decision "set off a firestorm of criticism." One group wanted the Cancer Institute to take a clear stand against younger women taking mammograms; others wanted it to uphold its previous recommendations that younger women should take the test (Kolata, 1995). Four years later, the Institute had decided to officially endorse the recommendation of routine mammograms for all women in their 40s, despite continuing uncertainties among scientists. The new recommendation was influenced, suggested journalists, by political considerations and the adoption of a patient advocacy perspective, rather than by pure science because "uncertain advice is not received kindly" by either pa

tients or physicians ("More Obese Adults," 1994). Last, is it justified to embark on interventions with messages and strategies

that are not fully tested in situations where the problem is defined as urgent and needing immediate action? Should an intervention be implemented even if it is based on limited resources, time, and expertise but justified by a caring per

spective or that whatever will be done is better than nothing?

4. The Targeting Dilemmas

Who should be targeted by the public health communication interven

tion? Should the intervention devote its resources to target populations believed

to be particularly needy or to those who are more likely to adopt its recommen-

dations?

Who is targeted by the intervention generates a host of ethical concerns. These include concerns of equitable reach: Should the intervention attempt to


reach all segments of the population, or should it target only specific population groups? This concern corresponds to consideration of entitlement: Who should be eligible to receive the potential benefits of the intervention? Should the entitlement be universal or selective (Turshen, 1989)? A second concern is whether interventions may in fact serve to widen the gap between those who have more opportunities and those who have less (Farley, Haddad, & Brown, 1996) 16 and whether the issues they emphasize are more relevant to certain cultural groups than to others. Similarly, concerns can be raised regarding the extent to which interventions address issues that are important to groups with special needs and the extent towhich interventions provide a forum for diverse perspectives on how the problem and solutions to address it are perceived and implemented. These concerns represent tensions between principles of justice and utility. According to the latter, one is obliged to maximize the greatest utility from the health promotion efforts (Hiller, 1987). However, when intervention resources are limited, should only those who are most likely to adopt the recommended practices be targeted, or should the intervention target those who are viewed as having the greatest need but are least likely to adopt its recommendations (Des Jarlais et al., 1994; Kahn, 1996; Marin & Marin, 1990; White & Maloney, 1990)?

Many health interventions aim to target populations considered underserved. The problem with this approach, suggest critics, is that to address inequalities in health care, one must face inequalities in other areas of life as well. Thus, despite sincere efforts, if interventions do not address structural or socioeconomic factors, disadvantaged target groups who may not have sufficient opportunities to adopt their health-related recommendations are not likely to do so. Consequently, the messages and activities are likely to have only a minimum of the desired effects, and the intervention approaches used can be deemed ineffective or a waste of precious public resources. 17 Considerations of overall efficiency and effectiveness may also play an important role in the decision of whom to target. One approach, typically referred to as a population approach, targets relatively large segments of the population.18 Its premise is that modest changes (e.g., in blood cholesterol levels or systolic blood pressure) in large populations produce relatively substantial changes in overall morbidity and mortality. This serves as the main rationale for many community-based interventions. The populationwide net impact; however, may not affect certain subgroups who may be particularly in need of an intervention or who may in fact benefit most from a targeted intervention (Fisher, 1995). As Geoffrey Rose


(1985)-a noted epidemiologist and proponentof the population approachsuggests, this tension illustrates the prevention paradox: an intervention strategy that "brings much benefit to the population [but] offers little (atleast on the short term) to each participating individual" (p. 38).19

An alternative targeting approach is to focus on those at high risk and aim to make significant changes in the health-related behavior of a relatively small number of individuals. The dilemma is whether the intervention should target those who seem to be most in need but are relatively few in number or devote its limited resources to reaching as many people as possible, thus resulting in increasing the health of the population as a whole. 20 Furthermore, certain groups may particularly benefit from an intervention, though others may not (Andreasen, 1995). After reviewing the results of a demonstration project to reduce smoking (the COMMIT Trial), Fisher (1995) concludes, "organizing programs to address relatively small pockets of heightened risk may be viewed as inefficient." Fisher proposes it would be best to target pockets of light-to-moderate smokers with no formal education beyond high school because this "may be the most efficient approach to accomplishing a substantial impact over the whole community" (p. 160). Yet this particular effort would exclude the heavy smokers, the primary target of the intervention.

Health interventions often serve as social experiments for policymakers or researchers. Policymakers want to know what works, what types of interventions can be considered effective. This leads to another ethical concern: Because such interventions are designed as clinical trials, they use designs in which some populations are not targeted and are not provided with resources or activities believed to benefit them. This raises the same kind of ethical concerns raised in the context of clinical trials: Is it ethical to deny certain people a "treatment" that may benefit them for the sake of proving its efficacy in a so-called scientific way?21

5. The Harm Reduction Dilemma

Should an intervention engage in strategies or support behaviors that are not socially approved or viewed by some as immoral, to prevent further harm to certain people?

On what grounds is it justified to provide new syringes to people who use injection drugs or to train them on how to clean injection needles, for the pur-


pose of avoiding HIV infection? Should adolescents be provided with contraceptive devices and education on sexual practices that are less likely to transmit

infections even if their parents or their community believes premarital sexual activity is immoral? Should interventions promote a message that an effective

way to avoid automobile accidents is to have designated drivers that take turns at refraining from excessive alcohol consumption?22 Interventions that adopt strategies that would answer these questions in the affirmative often justify it (though not always explicitly or consciously) on a harm reduction approach.

The harm reduction perspective was articulated in England in the mid-1980s and has gained momentum in Europe and Australia as a response to the urgency of preventing the spread of HIV infection in the area of injection drug use. Its proponents say that although it raises ethical concerns, such as sanctioning behaviors viewed as immoral or harmful to the individual, harm reduction strategies can in fact be justified on both moral and practical grounds. Syringe exchange programs, for example, can be justified on the basis of several ethical approaches that for the purpose here are characterized as the following: (a) doing good, because they protect individuals from the adverse effects of HIV infection; (b) utility, as findings on the reduction of HIV infection among users of injection drugs who participate in syringe exchange programs indicate they are also more likely to enroll in drug rehabilitation programs; (c) justice, because there are limited rehabilitation programs and opportunities for those who use injection drugs; (d) public good, because the users of drugs are an integral part of the community, and protecting the health of the community requires protecting the health of drug users (Des Jarlais, 1995); and (e) caring, because those who use injection drugs should be seen as people who need help and connectedness. Critics of harm reduction strategies, however, may believe their use reinforces immoral or harmful behaviors (e.g., sexual behavior or drug abuse). These views are contested by others who propose that such programs do not increase and may actually decrease the risk-promoting behavior. Some opponents may object in principle to supporting a practice they perceive as immoral, regardless of potential beneficial consequences.

DILEMMAS CONCERNIN(7INAVVERTENT HARM

Although well-meaning, and usually with distinct health-promoting objectives (Rogers, 1994), health interventions may contribute to unintended outcomes


that can be considered detrimental for individuals or society. The dilemmas specified in the following discussion concern three types of outcomes that may contribute to potential harm: (a) labeling or stigmatizing individuals, (b) denying the less privileged of pleasures they can afford, and (c) unfairly placing responsibility and blame on individuals or groups.

6. The Labeling Dilemma

By telling people they have a certain medical condition that puts them at riskJ does the intervention label them as ill? Does the intervention stigmatize certain individuals or affect their sense of identity by portraying the healthrelated conditions they have as undesirable or bad?

The labeling dilemma evokes two interrelated concerns regarding causing potential harm to direct and indirect target populations.23 The principle of do no harm, or nonmaleficence, is the obligation to bring no harm to one's client (Hiller, 19 87). The first concern is whether people's level of anxiety or worry is increased by assigning them to the role of persons who are ill (Barsky, 1988). On one hand, interventions' goals are often to encourage target populations to participate in screening activities and to identify those who are considered to be at risk for a particular disease to manage or prevent it. On the other hand, these interventions serve to frame particular medical conditions, such as high blood pressure or high levels of blood cholesterol, as diseases and to label individuals as patients (Guttmacher, Teitelman, Chapin, Garbowski, & Schnall, 1981; Moore, 1989; Shickle & Chadwick, 1994). This labeling may actually cause them harm (Barsky, 1988; Bloom & Monterossa, 1981). Individuals identified as possessing certain symptoms considered as risk factors find themselves in a peculiar variation of the Parsonian sick role (Parsons, 1958): They officially become pati~nts but they are not truly sick at the present; only at risk and needing help. This represents a new variation of the "at-risk" appellation (McLeroy etal., 1987), which obligates them to accept help from those considered experts and to actively cooperate with the agency or professional that offers the helping service. Labeled individuals are thus placed in the role of being obliged to follow a therapeutic regimen and to be in a state of continuous worry about their health. This raises ethical concerns not only about increased medical control over people's lives (e.g., concerns about consent; Forester, 1993) but also the extent to which social interventions affect people's senses of identity (Forester, 1993). Barsky (1988), a physician, observed high levels

Ethical DilemmasJ Practice- Oriented Questions 187

of anxiety among many of his patients, whom he labels the worried well. The dilemma is how to advise individuals that they may be at risk for potentially detrimental health complications without labeling them or contributing to their anxiety, which may adversely affect their well-being or senses of identity (MacDonald, Sackett, Haynes, & Taylor, 1984). The second concern associated with inadvertent harm is whether the intervention contributes to the stigmatization of people. The use of messages that employ fear-raising appeals may potentially stigmatize populations who are in that situation already and who possess the medical condition or attributes alluded to by the intervention as something that should be avoided or is greatly socially undesirable. This can spoil their identity or stigmatize them, as exemplified in the cases of individuals

who have been infected with HIV (e.g., Herek & Capitanio, 1993) or people with disabilities (Wang, 1992). Wang reports that messages against drunk driving or aimed to promote the use of seat belts, which depicted the horror of being confined to a wheelchair, were perceived by individuals with mobility disabilities as devaluing them and attacking their self-esteem and dignity.

How does one reconcile the use of persuasive appeals that on one hand serve to scare people about potential hazards and thus raise their motivation to avoid it but on the other hand may present a negative image of, label, and adversely affect the identity of others? One suggestion is that instead of using individual-level fear appeals, persuasive messages could appeal to people's altruistic motives, their sense of community, and willingness to help others. For example, as Wang (1992) suggests, messages that aim to prevent handgun injuries can focus on the incidence of injuries among children. In addition, messages can focus on the institutional factors that cause or contribute to the problem, such as particular corporate interests. For example, messages can focus

on the interests of gun manufacturers and the influence strategies of prohandgun lobbying organizations.

7. The Depriving Dilemma

Does an intervention that urges people to avoid practices associated with certain health risks serve to deprive certain populations of pleasures they may find hard to replace?

Health interventions that aim to change certain practices believed to put people at risk for disease or injury may inadvertently deprive them of behaviors


or products that have important significance in their lives or senses of identity. Typically, many behaviors associated with risky pleasures (Shaw, 1996) are consumption of foods or tobacco (or even risky driving) that are inexpensive in money and mental or physical effort and are relatively accessible to peopl.e

from lower social strata. Increasingly, it is argued, and this is supported by eVIdence on discrepancies in the adoption of health-promotion behaviors, individuals with greater means and socioeconomic resources find it easier to re

frain from practices considered risky. The quality of life of the latter may in fact suffer from what critics have labeled "forceful, evangelistic health propa

ganda" (Strasser et al., 1987, p. 190). Denying people inexpensive pleasures without providing them with alternative ones thus poses an ethical dilemma,

because the health intervention, although trying to do good, may actually harm those who cannot avail themselves of more costly alternatives.

Certain practices, such as smoking, although deemed unhealthy, may serve

people in disadvantaged situations as, their only means of perceive? control. For example, bans on smoking in hospitals have raised an outcry among advocates of individuals with mental health problems. They argue that expecting mental health patients "to kick the habit when they're going into the hospital, which is an awful event to begin with, is really cruelty to the n'th degree" and ,

"having a cigarette is a patient's one pleasure, the one opportunity for personal autonomy" (Foderaro, 1994, p. 44). Similarly, interventions characterizing certain foods or practices as unhealthy may deprive members of particular cultural communities of activities that have special cultural significance. Also similarly, certain practices (e.g., sexual relations with many partners, use of public baths, unprotected sexual intercourse) that may be viewed by certain people as an important part of their identity may be harshly condemned by intervention messages, which may be viewed by some people as an assault on their fragile personae (Odets, 1994). Practitioners or researchers engaged in the design and implementation of public health communication interventions should therefore carefully examine whether the implications of their call to relinquish cer

tain practices, foods, substances, or products may deny those who are particularly vulnerable £rom important rewards that they cannot easily substitute. Those who are particularly vulnerable may not be able to adopt the recommendations because of socioeconomic circumstances, special cultural meanings, or because the undesired practice serves as a ~eans for coping in a hostile social

environment. The dilemma of what to say to people in disadvantaged circumstances rep

resents the tensions between principles of doing good, promoting the public


good, refraining,from doing harm, and allowing for autonomous choices, as well as values associated with justice and caring. The messages developed in 1995 by the Gay Men's Health Center in a series called "Staying Negative-It 's not automatic" represent an attempt to balance these competing values (Illustration 6.1).

8. The Culpability Dilemmas

The emphasis on personal responsibility in interventions elicits several dilemmas:

By suggesting that people modify their behavior, and implying that they may be responsible for ill-health outcomes associated with it, are people unfairly blamed?

Is it fair to condone certain behaviors that entail considerable risk as socially approved and even socially desired while disapproving of oth~ that are considered irresponsible?

Should the intervention allude to the notion that individuals are responsible for the behavior of others, or does this cast an unfair burden on them?

With growing emphasis on individuals' lifestyle behaviors as prominent risk factors for ill health, personal responsibility has become a highly visible and prominent theme in many health interventions (Mcleroy et al., 1987).24 Their messages often urge individuals to take responsibility for their own health and to adopt health-promoting behaviors. The emphasis on individual responsibility presumably is based on the assumption that particular health

related behaviors are freely chosen or at least under the voluntary control of the individual. Those who fail to adopt practices promoted as health protective can be characterized as irresponsible by implication. The intervention's intended populations, however, may not adopt recommended practices because of the constraints imposed by economic or sociocultural circumstances and therefore should not be held accountable for not adopting the h~alth-promoting practices.

The issue of accountability or personal responsibility, when raised in the context of health promotion efforts, underscores a highly contested moral issue in social interventions-victim blaming (e.g., Beauchamp, 1987; Crawford, 1977; Eisenberg, 1987; Faden, 1987; Marantz, 1990; Ryan, 1976). It refers to locating the causes of social problems within the individual rather


"I like sex with someone I don't know.,It makes me feel most alive, but a lot of times it happens after I've been out drinking. When I'm feeling good is when the condoms get clumsy. 1 just tell him to not bother. 1 don't want to stop drinking but 1 spend days panicking wondering if I'm going to get infected when I'm too wasted to care."

staying negative - it's not automatic We have free workshOps that can help you stay llDIDfect~d. By ~g about the se:. you are having, what you like about it and what you don t, you can make partying and sex - safer. Call today.

Illustration 6.1 © 1995 Gay Men's Health Crisis, photos by Allen Frank/Frank Frame


than in social and environmental forces. On one hand, because individuals are viewed as autonomous and able to make voluntary decisions regarding their behaviors-especially those characterized as related to lifestyle-the responsibility for modifying their behavior is viewed as primarily their own. On the other hand, many who do not adopt health-promoting behaviors because of their social or economic circumstances are viewed as particularly vulnerable to antihealth influences. This argument adds complexity to the issue of personal responsibility or culpability: When are we to consider that the person's behavior is voluntary and when is it to be viewed as affected by powerful cultural or institutional factors (McLeroy et al., 1987)?

The question of how to determine what is voluntary leads us to another di

lemma associated with responsibility: Should one be free to choose whether or not to adopt practices that may lead to illness or disability? Furthermore, who

should be responsible for adverse outcomes that result from people taking risks with their health? Some claim that people who take risks with their health impose burdens on others and society as a whole, especially when the public needs to take care of them or pay for their health care or disability (Mclachlan, 1995; McLeroy et al., 1987; Veatch, 1980). This points to tensions between ethical principles of personal autonomy and the public good, and it raises the following questions: Should health interventions promote mc::ssages that suggest that individuals should be liable for increased costs they may place on the medical care system, under the assumption that their voluntary acts may cause injury to others? Should people who do not adopt what are considered responsible practices be charged with higher health insurance premiums or denied all or part of their insurance claims if they do not, for example, use seat belts (Beauchamp, 1987)? What behaviors can be characterized as truly voluntary, and when do we not hold the person culpable (Veatch, 1982)? This dilemma leads to the dilemma of certain risk-taking and injury-prone behaviors being socially sanctioned and even approved of as socially desirable (e.g., sports or dangerous occupations), whereas others are not. What are the moral criteria for making such distinctions? Should individuals who engage in socially nonapproved health-related risks be held accountable for their injuries or diseases while those whose socially sanctioned behaviors may lead to the same kind of consequences are seen as heroes (Keeney, 1994)?

The third dilemma concerns the extent to which one is responsible for the behavior of others. Interventions often disseminate messages that appeal to significant others to ensure that the person who is seen as being at risk will ,


adopt the recommended practices.2S Although these interventions intend to do good by using what they consider effective persuasive messages or to emphasize the importance of caring (Noddings, 1984), they may do harm by implicitly blaming significant others. This may occur when the person who is believecl to be at risk does not adopt the recommendations or when the significant other feels they are not capable of influencing the person at risk. Thus, when persuasive appeals turn to significant others as a means to influence health outcomes, we need to closely examine the ethical implications.26

Another ethical concern regarding blame and responsibility is whether an intervention makes a claim that one's actions are necessary or sufficient to cause or prevent the ill-health problem. If the messages frame the individual's behavior as a sufficient condition for causing the potential harmful outcome, that raises serious ethical concerns because this insinuates that it is the individual's behavior that is the only cause for ill health.27 Although most intervention messages do not explicitly make such allegations, people who are increasingly bombarded with messages about personal responsibility may interpret them as such.28 For example, in a series of "Health Notes" included in a kit for professionals produced by the NHLBI and reproduced by local public health communication intervention programs, messages were prevalent that stated "It's up to you: High blood pressure can be controlled, but you are the only person who can control it" [italics added].29 The means to control it, according to the printed material, were weight control, limited salt intake, avoidance of alcohol, engaging in exercise, and complying with a medication regimen. By implication, if one did not adopt these practices, this neglect would be a likely reason to get a stroke. On the other hand, this can be considered an empowering message that lets people feel they are in control. A television PSA aimed to encourage individuals with elevated blood pressure to stay on treatment, produced by the same organization, elicits the same dilemma: It shows stark scenes of homes without their inhabitants and the voice-over solemnly tells viewers that particular individuals who did not take their high blood pressure medication appropriately, indeed died, leaving their loving family members behind: "Meet the people who didn't take care of their blood pressure .... Mr. Remos left a beautiful family." Clearly, the implication is that these people were not responsible in taking care of their blood pressure; therefore, their

family now suffers. These messages imply that the persons' nonadherence caused their deaths and that they neglected their fundamental responsibility. The person who did take care-is still alive. Thus, persuasive messages may


inherently involve the potential inducement of guilt feelings or obligation (Faden, 1987).

An ~mphasis on responsibility, as discussed in the labeling dilemma, can lead to distortions in attribution of blame. In a report on findings from a focus

group conducted in a community fraught with socioeconomic problems, respondents tended to blame themselves or their "weak characters" for not adopting the recommended medical regimens to control high blood pressure.30 These respondents did not consider the possibility that socioeconomic and institutional factors may serve as significant barriers, irrespective of their personal dispositions. Similarly, Jeffery et al. (1990) describe findings from a study of a hypertension prevention program in which the participants prof

fered different attributions of causes for their failures to adopt recommended preventive behaviors. Participants who were experimentally assigned to the weight-loss groups were significantly more likely to blame themselves for their problems with adherence than were those assigned to the non-weight-loss groups. They tended to internalize the blame and attribute it more to their personal characters rather than to external or situational attributions (e.g., lack of support or environmental conditions). It is interesting that the differences in the types of attributions did not predict weight loss or other medical outcomes. This phenomenon of self-blame echoes critics' concerns regarding blaming the victim31 and justice or fairness, because health promoters have the obligation to treattheir target population fairly in terms of burdens (e.g., risks, costs) and benefits (Hiller, 1987).32

Ethical concerns associated with justice thus raise the issue of whether the intervention provides all members of the population with reasonable opportunities to pursue the goals emphasized in the intervention (Daniels, 1985), what should be considered as reasonable opportunities, and who should decide on the definition. The issue of equal opportunity was raised by focus group members in a community program studied by the author (Guttman, 1994). Intervention messages that emphasized choice and responsibility to prevent heart disease (originally produced by the NHLBI) were contested by members of the focus group. The messages state that one's "choice begins at the grocery store," but the members felt that what people in the community could actually con

sume was very limited because they were restricted by the relatively high prices and low-quality produce available to them at the only grocery store in walking distance. The intended population would mainly use the store because it did not have easy access to other food outlet options.33


Justice is providing equitable opportunity to those who are more restricted in their current options. Daniels (1985) explains that providing an opportunity to the less advantaged does not necessarily mean that individuals can purchase what they would like to, but it does mean that they should be provideCil with equal opportunity to purchase nutritious foods viewed as necessary to maintain good health. This raises concerns regarding principles of justice, as indicated by epidemiologic studies: Decreases in morbidity and mortality from heart disease are usually more prevalent in the more affluent population, because they are more apt to adopt healthier lifestyle behavioral modifications (e.g., Blane, 1995; Thomas, 1990; Whitehead, 1992; Wtiliams, 1990; Winkleby, 1994).34 An additional concern associated with using the notion of

personal responsibility as a persuasive strategy for health promotion is the extent to which the emphasis on an individualistically oriented conception of personal responsibility raises people's expectations ofthe health care system as a whole. This issue is discussed in the dilemma concerning the promise of good

health, elaborated in the discussion to follow.

DILEMMAS CONCERNING- POWER AND CONTROL

Power and control can be maintained through indirect means, including ideologies and implicit coercion (Mumby, 1988). Concerns associated with power and control thus need to identify existing or potential patterns of control and privilege in public health. communication interventions (see Duncan & Cribb, 1996; Salmon, 1989, in the adaptation of a Faucauldian perspective). The following three dilemmas focus on potential manifestations of power and control

in three types of instances.

9. The Privileging Dilemma

By focusing on specific health problems or particular ways to address them, does the intervention privilege certain stakeholders or dominant ideologies?

By focusing on particular medical conditions, interventions, by definition, prioritize these conditions and privilege certain individuals or social institutions over others. First, framing the issue in medical terms serves to privilege


the health and medical institutions that have framed it as such, including, more specifically, agencies and professionals who specialize in treating the condition and pharmaceutical companies whose products have been developed to treat it. This raises ethical concerns regarding who is privileged (both purposefully and inadvertently) by a certain intervention and what the implications are for society as a whole. Many commercial enterprises can profit from intervention efforts by increasing markets for their products or services (Freimuth et a!., 1988; Wang, 1992), and often, as illustrated in the case of the National High Blood Pressure Education Programs and the National Cholesterol Education Programs, interventions may specifically act to support the authority of biomedical professionals by urging the public to see their doctors. In fact, one of the criteria for the success of these interventions is the increase in the number of visits to physicians.

According to Zola (1975), labeling a particular physical condition as a medical condition or disease has serious political, economic, and social consequences and privileges the medical establishment. Once a condition or behavior is defined as a matter of health and disease, the medical profession is thereby licensed to diagnose, treat, control, or intervene. The mere act of characterizing a certain level of blood cholesterol as an important medical condition, and having the detection and treatment of this condition promoted through an intervention, potentially results in placing a large number of individuals in the social position of patients and in the creation or enhancement of a whole industry of screening and monitoring paraphernalia. It may also privilege manufacturers of particular food products. This raises ethical concerns regarding the extent to which one condition should be prioritized over others and the extent to which particular stakeholders' perspectives and interests are given more prominence over those of others. A related concern is, to what extent does an intervention prioritize particular social values and beliefs over others? Values related to individual responsibility, individual-level solutions, and market autonomy are often emphasized in health interventions. This emphasis is likely to reproduce values dominant in American culture that include individualism (Bellah et a!., 1991), a distrust of government intervention, a preference for private solutions to social problems, a standard of abundance as a normal state of affairs, and the power of technology (Priester, 1992a). To what extent does a public health communication intervention contribute to sustaining or reproducing certain beliefs and social and cultural institutions that support them, intentionally or not?


Another concern is, to what extent do interventions privilege particular agencies or groups by collaborating with them or providing them with resources or legitimacy? Interventions tend to work with groups in the target community that are established and already have resources, thus emphasizing prin(£iples of utility. Critics maintain that this can help perpetuate the power of these groups while depriving less-established or non-mainstream organizations of potential resources and legitimization. Although interventions may at

tempt to involve individuals and groups from a wide spectrum, constituencies who are given priority are most likely to be established agencies and groups that already have considerable resources and networks or are predisposed to

the topic of the intervention. Consequently, they are less likely to address the needs and concerns of those who are unaffiliated and who are relatively marginalized. As a result, the latter are least likely to be given the opportunities to get involved in policy-making processes related to an intervention that aims to affect their lives (Wallace-Brodeur, 1990). Last, an additional concern is the extent to which certain groups or organizations are more privileged by being able to produce (persuasive) information and get it disseminated (Rakow, 1989). To what extent do particular organizations or groups have more access to information that will support their claims regarding what health issues should be focused on or what strategies should be adopted?

10. The Exploitation Dilemma

May involving community-based or voluntary organizations in a health in

tervention serve to inadvertently exploit these organizations, although such in

volvement may support values of participation and empowerment?

More and more interventions, including those sponsored by the federal government, follow a model of using local agencies or organizations to imple

ment much of the intervention process. This raises ethical concerns regarding the extent to which interventions create expectations that voluntary groups will carry out functions that should be served through public services. For example, national and state-level initiatives rely on local screening activities that take place through the collaboration of local agencies and voluntary groups to

achieve the programs' official goals. These programs' long-term goals are to institutionalize these types of activities so that local organizations can continue them in the future without sponsorship or funding. Capek (1992) and Green


(1989) note that there is a potentially problematic aspect related to the goal of institutionalization, of having community organizations eventually take over the mission of the (funded) intervention program, especially if that mission entails service delivery. As Green has explained earlier, community organizations

should not be expected to take over as permanent substitutes for federal agencies; trying to do so can dis empower them and divert scarce resources from their primary goals. On one hand, local involvement promotes democratic goals. On the other hand, concerns can be raised regarding the extent to which the involvement of the group or agency in the intervention serves this group or the community it represents in the long run. Are organizations that become involved being exploited by the program because it may not serve their interests in the long run? In addition, are its constituents given the opportunity to decide on the goals and priorities of the intervention? This also raises concerns regarding the extent to which particular organizations should be obligated to participate and whether certain organizations are viewed as having obligations for community members' health. Similarly, should organizations that choose not to be involved be sanctioned? Last, in what ways does the intervention enterprise itself serve as a means of control and subjugation of individual or local framing of social and health-related issues? The latter is further deVeloped in the control dilemma, described in the following discussion.

11. The Control Dilemma

May implementing certain health-promoting interventions serve to increase state, corporate, or organizational control over population or organization members?

States and organizations increasingly engage in surveillance activities to identify, quantify, and monitor health intervention activities. In what ways does such surveillance-often a primary condition for obtaining the support of dominant social institutions-constitute a structure to control or regulate people's behaviors? Surveillance has become a prominent feature of modern life

(Duncan & Cribb, 1996) that enables dOminant institutions to learn about what people do or do not do, including their purchasing patterns, their medical states, and their cultural beliefs. More so, the sites and means to monitor people have become increasingly ubiquitous, ranging from the ability to obtain detailed information from individuals' credit card purchases, phone ~nd elec-


tronic media uses, to genetic screenings. Concerns about implications of surveillance as they relate to the notion of control have already surfaced in the context of work organizations and can be applied to municipal, state, and national contexts as well. Work organizations increasingly offer what are called wellness and disease prevention or health promotion programs. The mere provision of such programs in work organizational contexts often indicates the success of health interventions. Obviously, work site disease prevention activities, as part of a health intervention, have numerous advantages. Work site interventions can provide interventionists with access to particular groups and present workers with opportunities or even tangible incentives to participate in health-promoting activities.3s Justifications for these activities relate mostly to principles of doing good (for the employees) and utility (e.g., increasing productivity, decreasing absenteeism, and enhancing the organization'S image). Nevertheless, numerous ethical concerns have been raised regarding the work site as a place to promote health (e.g., Hollander & Hale, 1987; Roman & Blum, 1987).

One of the major concerns is the extent to which involvement with employee health gives the work organization a mandate to literally pry into what until now had been considered employees' private affairs. With health linked to lifestyle, organizations can engage in activities to find out what their employees do on and off the job-in the name of concern for their employees' health. They can use this information to justify managerial decisions not necessarily in the interest of the employees. Similarly, management can make presumably health-related demands on employees that are not directly linked to their work (Conrad & Walsh, 1992; Feingold, 1994). The so-called "new health ethic" may serve as a new vehicle for enhancing worker discipline, screening for undesired workers, or fostering uncritical loyalty to the company, say these critics. Ethical concerns related to autonomy and privacy and justice can be raised in this context. Specifically, to what extent are individuals discriminated against because they are characterized as potential liabilities to the organization (Feingold, 1994)? Furthermore, surveillance activities, by framing what is good and bad or normal, become on their own a mechanism of control and can thus serve to "shape the public domain and thereby the self-consciousness of the governed" (Duncan & Cribb, 1996, p. 345). Critics have suggested that wellness and health promotion programs, especially in work organizational contexts, typically conStruct disease etiology in terms of individual behavior and individual responsibility for being healthy, and they adopt a biomedical framework for assessing risk and risk factors (Alexander,


1988). Alternative conceptualization of risk factors for illness include social and institutional factors, such as the extent to which workers have latitude for decision making in their jobs (e.g., Karasek & Theorell, 1990). This raises concerns regarding the extent to which it is justified for health interventions to mainly emphasize one particular version of health-risk etiology, an issue raised in Chapters 1 and 3 regarding the way problems are defined and further examined in the dilemmas related to social values, which follow.

DILEMMAS CONCERNINf,- SOCIAL VALUES

Do public health communication interventions turn "good health" into an ideal? Do they contribute to making health a "super value" that should be vigorously pursued? Is it implied that "good health" is what "good people" are rewarded with? These are some of the concerns associated with the growing emphasis on health as a value in widely disseminated public health communication interventions. Intervention planners need to consider how their interventions contribute to cultural changes that include the reinforcement or transformation of specific values or ideologies. Over time, interventions as an aggregate produce cultural changes, even if they do not change individuals' behaviors (Pollay, 1989). The three dilemmas presented in the following discussion reflect these concerns by focusing on issues characterized as distraction, promises, and health as a value.

12. The Distraction Dilemma

By emphasizing health-related issues in personal, organizational, and societal agendas, does this emphasis serve to distract people from important social issues?

Having health-related issues capture such a prominent position on personal and public agendas serves, suggest critics, to distract individuals and society from other, more significant problems, such as economic equity or environmental hazards.36 As communicative action, health interventions can be viewed as framing issues and selectively drawing attention to them while deemphasizing others, thus making the issues promoted by the intervention seem more important. Communicative practice, argues Forester (1993), can-


not be viewed simply as an enactment of goals but as the "practical comm~ni~~tive organizing (or dis-organizing) of others' attention to relevant and sIgmfIcant issues at hand" (p. 5). Pollay (1989) reiterates this argument:

Interventions also serve to set agendas, direct people's attention and order people's priorities. Public health communication programs aimed at making individu

als more responsible for their diets may also direct attention away from govern·

ment and industry policies putting pollutants, toxic waste and carcinogens into the

ecology and food chain. (p. 190)

These assertions are supported by research findings from the agenda-setting

perspective according to which campaigns to prevent dru~ abuse were found

to influence public perceptions on the importance of these Issues (S~oe~aker, 1989). Public health communication interventions can serve to prIorItlze or frame certain issues as important and thus may serve to distract attention from others that do not get government support. Taking this claim a step further, as discussed in Chapter 4, educational messages on how to adapt to current schedules or to limited resources can serve to distract people from institutional or structural conditions that limit their activities or in fact produce conditions that pose a risk to their health. They can also serve as a vehicle to advance peo

ple's adaptation to situations that are not favorable to them. ~~rshen (19~9) offered an example in the area of nutrition education: "NutrItIOn educatIOn too often shows people how to adjust to intolerable situations; in an extreme example, South African nutrition education programs teach Blacks how not to starve on starvation wages" (p. 196). Bellah et al. (1986, 1991) also express their concerns about distraction, but their discussion moves us more to a macro

sociopolitical arena; they described social institutions as forms of pa~ing attention to particular issues, on one hand, but on the other hand, as SOCIally organized forms of distractions. The process of distraction is significant, they ex

plain, because of its impact on the functioni~g of a. ~emocratic ~ocier:: "One way of defining democracy would be to call It a pOhtICal system III whICh people actively attend to what is significant" (Bellah et al:, 1991, p. 273).

Public health communication interventions, partIcularly those that employ social-marketing approaches, tend to emphasize and affirm mainly individual-level solutions. As such, they raise the following concerns: To what extent do interventions affect public perceptions and emphasize individual-level

solutions as the main course of action, at the expense of other approaches (e.g., organizational or societal)? To what extent does the intervention promote only


a lifestyle-modification agenda and not present the public with alternative per-. F 37

spectlves ( arrant & Russell, 1987)? These may include messages on how

health risks of the public are intricately vested in competing interests of powerful organizations, such as the food and tobacco industries, government interests, or the medical profession.38 Green and Kreuter (1991) distinguish between reductionist and expansionist approaches to health interventions. In the former, health is identified from broader social issues; in the latter, the specific health issue of the intervention, which is often assigned to the practitioner as its sole mission, can serve as a basis for consideration of a broader range of social issues. But this is not easily accomplished. As a staff member working on a fed

erally funded iritervention explained in an interview I conducted in 1992 he , did not see his role as a social-change agent in the sense of trying to change structl,lral factors. "If I would have wanted to do that [social changes], I would have gone to be a social worker," he emphatically said. In an interview connected with another initiative, also in 1992, a practitioner lamented to me that neither she nor the other staff members in their health promotion program were trained in community development. They lacked skills, she said, to develop programs to address community-level or structural factors, and therefore their program focused on increasing public awareness of the topic and promoting personal behavior changes. Certainly, the issue of affirming multiple types of causation of health and illness poses challenges to researchers and practitioners: What is the ethical mandate of the researchers or practitioners? Are they mandated to emphasize only the types of messages directly related to the specific domain of behavior change of the intervention, thus possibility distracting attention from other causes? Are they obligated to provide messages on sociocultural or other factors and ways to assess and address them?

13. The Promises Dilemma

Do health interventions that urge people to adopt particular practices and suggest that by doing so, they will be healthier, make promises that may not be beneficial to the public?

Interventions tend to emphasize good health as a reward for adopting what is considered a responsible lifestyle. Their messages may promise people that if they adopt recommended regimes, they will be rewarded with good


health. This, maintain critics, reinforces the notion of individual needs as the basis for health care and is problematic not only from a practical perspective but a moral one as well. Callahan (1990) and others (e.g., Barsky, 1988) argue that a major challenge facing the health care system is the escalating expectation9 of the public for medicine and health care. Two related premises and promises that underlie the current health care system are flawed, suggests Callahan (1990). The first is that health care should emphasize meeting individual needs, and the second is that this can be done econpmically and in an efficient manner. From a practical perspective, it is argued, the more individuals' expectations are raised, the more they will increase their demands from the health care system, which in turn will increase demands for expensive procedures and services for an ever-increasing range of what can be considered medically related (Gaylin, 1993). According to Callahan (1990), there is a direct conflict between preferences of the individual, whom he suggests, given the choice, will tend to demand the most expensive and comprehensive health care possible, and the depleted limited resources of society.

The ethical concerns raised in this context mainly relate to doing harm, by raising expectations that cannot be met, and the public good, by increasing demands on an overtaxed and costly health care system. Also, the emphasis on personal rewards may serve to deemphasize caring and connectedness to others and the value of relationships (Noddings, 1984). Another concern relates to justice. There is a growing gap in the use of health care between those who have easy access to medical services and those who do not (Gold & Franks, 1990; Mandelblatt, Andrews, Kao, Wallace, & Kerner, 1996; Thomas, 1990). On one hand, individuals who have the opportunities to adopt recommended health-promoting regimens have raised expectations and will increasingly see medicine as an unlimited social good. On the other hand, those who have fewer opportunities to adopt health-promoting regimens ma! be made to feel inadequate, guilty, or hopeless. In addition, with more and more ~ersonal and social issues (e.g., infertility) viewed as potentially solved by medIcal technology-and therefore within the domain of medical care-it can be argued that those who have more opportunities will be tempted to demand even more medical services. These demands, argues Gaylin (1993), will increase the cost of the health care system to society beyond any cost-saving measures proposed by health insurance reform policies. Those who have fewer opportun~ties will be less likely to use current resources, which can adversely affect theIr health status (Gold & Franks, 1990; Thomas, 1990). This corresponds to the phenomenon of the knowledge gap (Dervin, 1980; alien et aI., 1983; Rakow,


1989) and raises ethical concerns regarding justice and fairness. The promises that cannot be fulfilled lead to the final dilemma presented in this paper: the implications of emphasizing health to such an extent that it becomes cast as an ultimate value.

14. The Dilemma of Health as a Value

By making health an important social value that should be purSued by the public, does the intervention promote a certain moralism that may clash with othe: important social values?

Broadening the definition of the role of medicine in disease and health and raising people's expectations accordingly raises additional concerns: Do public health communication interventions, by emphasizing the importance of health and a healthy lifestyle, contribute to health becoming an ultimate value? (Gillick, 1984).39 Preoccupation with health and turning it into an important value may distract people from other areas of human existence. As Callahan (1990) warns,

Health sought for its own sake, or because of the jobs or profits it produces, leads to a kind of personal and social madness. One can never get enough or be too safe. We will spend too much on health, be in a state of constant anxiety about mortality,

and be endlessly distracted from thinking about more important purposes and goals of life. (p. 113)

Promoting health as a value may also have implications for people's perception of self and others or their senses of identity. An emphasis on health, argue critics, may serve to promote values of individualism at the expense of values of connectedness and caring. For example, slogans such as "It won't happen to me," "It's your health," "Take care of yourself," reflect an emphasis on individualism and a separation between those who value health and those who do not (Burns, 1992):40

"Take care of yourself "-"assume responsibility for your own health"-"assess your own risk"-"personal wellness"-These are all slogans of a perspective on health that is essentially individualistic. It's what you'd expect in a culture that sees

the self as separate and looks at human relationships as market transactions. It is self-centered and body-centered .... Prevention programs that over value the self have the benefit of helping individuals stay well, but they allow the precise separa-


tion of self from others: health vs. sickness, we versus them. They promote a concentration on the self, neglecting the possibility that although illness may be em

bodied, health is something we share with others. (pp. 10-11)

Jnterventions for AIDS prevention tend to emphasize the use of so-called negotiation skills for achieving sexual partners' compliance in adopting safer sex practices (e.g., Fisher & Misovich, 1990; Franzini, Sideman, Dexter, & Elder, 1990). The word negotiations, though, can connote an interchange that emphasizes personal interests, similar to marketplace transactions (Burns, 1992), one of which is personal health, rather than values that emphasize relationships or caring. This critique does not suggest that we should not help people enhance their communication skills with sexual partners to prevent potential harm. Rather, it raises the concern that this type of emphasis can put women and members of particular cultures, who tend to greatly value caring and relationships, in a double bind (Lyman & Engstrom, 1992; Scott & Mercer, 1994).

A related concern is, To what extent does the promotion of health as a value by interventions contribute to the medicalization of life (Fox, 1977) or, using Habermas's terms, the colonization of human experience (Habermas, 1979)? Callahan (1990) argues that with health increasingly being viewed as an important value, definitions of what is a "good life" become dependent on medical criteria. Barsky (1988), a physician who became concerned with people's growing obsession with health when he saw many of his patients become what he calls the worried well, makes a similar point:

The point is that the pursuit of health can be paradoxical. Secure well-being and

self-confident vitality grows out of an acceptance of our frailties and our limits and our mortality as much as they can result from our trying to cure every affliction, to

evade every disease and to relieve every symptom. (pp. xi-xii)

Callahan (1990) emphatically adds that this can result in too much of an "obsessive ... quest for health" (p. 37).

Broadening (or distorting) the definition of health into a construct of all-inclusive wellness that encompasses physiological, psychological, and social factors, including character traits, personal appearance, criminal activities, moods, and desires, may serve to medicalize human existence. Increasingly, human experiences of life, birth, pain, death, coping, and joy are defined as health relat~d, and people, it is suggested, tend to lose the capacity to live and


cope without medical definitions (Fitzgerald 1994) 41 EthI·Cal co . ,. ncerns, In o~her words, focus on the extent to which health interventions serve to colo-D1Z~ or medicalize human experiences, foster dependency on medical institutIons, or deemphasize people's cultural and spiritual well-being. To this Mars~all Becker (1986), in an article titled "The Tyranny of Health," adds ~ warnmg that health has become a "New Morality,,42 and that

healt~ promotion, as currently practiced, fosters a dehumanizing self-concern that

substl~t~s personal health goals for more important, humane, societal goals. It is a new religIOn, in which we worship ourselves, attribute good health to our devout

ness, and view illness as just punishment for those who have not yet seen the Wa ~~ ~

.Health ~us becomes a metaphor for self-control, self-discipline, selfde~al, and will power. It becomes a moral discourse and "an opportunity to reaffirm the values by which self is distinguished from other" (Crawford 1994 p. 1353). ~ie~ing health as an ultimate value may harm those who, ac:ordin~ to these crIterIa, are portrayed as not being healthy by making them feel they have been punished or are unworthy. .

. The dilemma of treating health as a value may be addressed by adopting a SOCIal rather than "a distinctive biological view of health" (Levine, Feldman, & £linson, 1983, p. 400). Asocial view of health doesnotfocus on the absence of organic and mental disease but on the way it influences individuals' quality of life, their ability to function, perform, and do what they want to do (Levine et al., 1983), and the extent to which one can enable their self-actualization. Aso

cial view of health reminds us that health is likely to be conceived and valued differently across cultural and social groups whose needs and social conditions

may differ. Robertson and Minkler (1994) cautioned, however, that even the adoption of a social conceptualization of health, and having health val~ed as a

resource rather than a commodity, risks the commodification of health. The definition of health may again be "conferred by a new set of experts with new knowledge bases and new skills" (p. 299).

PRACTICE,ORIENTED QUESTIONS

This chapter concludes with a series of practice-oriented questions presented in four tables. They provide examples of how dilemmas associated with ethical


concerns can be applied to the design and implementation of interventions, the assessment of their goals, and the evaluation of their outcomes. Such questions can be used for both analytic purposes and as a basis for empirical and design work. For example, questions associated with dilemmas regarding the use of policj.es that place restrictions on people's behavior can help formulate the development of designs that take into consideration the considerable ambivalence, resistance to, and often lack of enforcement of such policies.43 Intervention designs may thus incorporate methods to study and understand the intervention population's values, beliefs, and preferences regarding policy restrictions as well as methods to develop opportunities to enable and facilitate discourse among various intervention constituencies on the pertinent issue. In the area of targeting, articulating questions about the extent to which the intervention indeed reaches different segments of the population may help compel intervention designers to closely examine the strategies they use to reach various audiences and to test the extent to which the intervention efforts may not reach certain individuals or populations. Such questions may also prompt them to closely consider what populations they may decide to exclude and how to justify such an exclusion. For example, they may decide to exclude populations that can afford to pay for services provided by the intervention. These questions may need to be addressed through advocacy, public policy, and con

siderations of entitlement and resource allocation. Questions about labeling may help interventionists reconsider what types

of persuasive messages should be used in the intervention. Labeling concerns may influence the way focus group interviews are conducted because these often serve campaign designers as a basis for the development and selection of persuasive appeals. Consideration of labeling may encourage designers, in their formative research, to explore messages and persuasive approaches that specifically avoid the potential of labeling and stigmatization. Perhaps, they may choose to explore ways to involve and engage intended audiences in the health-promotion effort through values associated with social responsibility and the public good instead of focusing mainly on appeals to personal

vulnerability. If the intervention employs participation or involvement as its strategy or

goal (as discussed in Chapter 5), questions about potential exploitation of local voluntary organizations may contribute to (a) the specification of the expectations of the intervention from each organization that participates in the intervention and (b) the analysis of potential short-term and long-term costs that


may be associated with this participation. Design implications might be the provision of criteri~ for choosing long-term strategies that will ensure that the organization's resources will not be depleted or that if the intervention provides services that should be provided by public agencies, public policy will ensure that service provision will not rely on community voluntary efforts (e.g., by incorporating public policy goals associated with resource allocation). Tables 6.1 through 6.4 present examples of practice-oriented questions, one table for each major area of general concern. The dilemmas described in this chapter are identified in the first column. The second column presents examples of questions, the third, examples of design implications, the fourth, justifications for why the activity may be pursued by the intervention, and the fifth column lists potential ethical concerns that may need to be balanced with these justifications. The questions can be further adapted to the specific context of the interventions and can be used in their assessment and the design of evaluation criteria. Because the enterprise of health interventions includes diverse health promotion and disease prevention efforts, these dilemmas and questions can also be applied and adopted to other contexts. For example, ethical concerns associated with targeting, persuasion, or distraction are applicable to all interventions that aim to reach particular p~pulations, regardless of the strategies they employ and whether they aim to curtail illicit drugs or cigarette sales through stricter enforcement or to educate workers on the importance of adopting safety precautions.

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Table 6.1

Dilemmas

Persuasion

Coercion

Questions Drawn From the Strategies Dilemmas

Questions

Is it justified to use highly persuasive tactics to achieve intervention goals? Is it justified not to use highly persuasive tactics, even if they might effectively

achieve intervention goals?

Is it justified to promote policies that regulate or place restrictions on individual's behaviors even if they may be effective?

Is it justified not to promote policies that place restrictions on individual's behavior but might be effective?

Is it justified to promote policies that place restrictions on the marketplace which in turn restrict individual choice?

Would restrictions on the marketplace or the social environment help distribute the responsibility for people's well-being across the community or would these restrictions penalize particular individuals?

Would regulation such as an excise tax pose relative hardship on those who are less economically advantaged?

Design Implications

Choice of strategies Evaluation of

effectiveness


effectiveness

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Targeting

Harm reduction

Should the intervention's resources be devoted to populations believed to be partic~larly needy but hard to reach or to those who are more likely to adopt Its recommendations?

Does the intervention widen the gap between those who have more socioeconomic advantages and those who have less in social and healthrelated outcomes?

Does the intervention reach all segments of the population to the same extent?

Are issue~ t~at ?re m~re salient to the more dominant cultural groups given more priority In the Intervention?

Does ~he intervention address issues that are important to groups with special needs?

Should the intervention engage in strategies which support behaviors that are not socially approved or are seen by some as immoral, in order to prevent further harm to certain populations?

Should the interventions promote messages that may reduce people's exposure to immediate harm but may serve to maintain practices that can cause ill health in the long run?

Choice of strategies Targeting Evaluation of

effectiveness


effectiveness

Justifications

Doing good Not doing harm

Doing good Protecting others Autonomy Market autonomy Public good justice

44

Doing good justice Care

Doing good Utility

Ethical Concerns

Autonomy Belief Consent Doing good Utility

Autonomy Consent Doing good Utility justice

Justice Care Utility

Support of immoral activities

DOing harm

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Table 6.2 Questions Drawn From the Inadvertent Harm Dilemmas

Dilemmas

Labeling

Depriving

Questions

What are the implications of labeling a person as a "patient," "at risk," or "having a disease" after getting them to be screened for a particular symptom?

Does the intervention raise the level of anxiety, fear, or guilt among target populations?

Does the intervention stigmatize certain people by characterizing them as having a particular undesired medical condition?

Might the intervention serve to deprive disadvantaged people of accessible pleasures without providing them with alternative options when decreeing that practices or behaviors associated with certain risks should be avoided?

Does the campaign deprive people of cultural activities that are of particular significance to them?

_Lii 4 _..-,, __ ~ ..... _ .......... ____ = ~~"'"~ ....

-..' "'" ,("". ~", ~'"'' I ~"":!i- .i<"",..-;-.m<j4;i\ • ,:. -'" "", -Culpability To what extent should one be free not to adopt practices

that might put them at risk? Does the intervention claim that adopting its recommen

dation is a necessary or even a sufficient condition for what is characterized as good health?

To what extent does the intervention imply that one person is responsible for the health-related behaviors of others (e.g., spouse, friend, employee) and to what extent should they be held responsible?

Should the intervention promote messages that individuals should be liable for the societal costs of their risk-taking voluntary activities, and what are considered hazardous or antihealth behaviors?

Which behaviors are truly voluntary, for which a person can be held culpable, and which are not voluntary, thus exempting the person from full responsibility?

What behaviors with high injury potential should be seen as socially desirable, which are not, and what are the moral criteria for making these distinctions?

Are individuals inadvertently blamed or stigmatized by the campaign if they do not adopt its recommendations?

Does the intervention rely on personal responsibility messages as its main strategy for getting target audience members to adopt the recommended practices?

Do all target populations have reasonable opportunities to adopt the recommended practices?

Who decides what is reasonable or unreasonable risk-taking behavior?

Design Implications

Choice of strategies Choice of types of messages

or appeals

Choice of strategies and appeals

Evaluation of intended and unintended outcomes

- iii

Choice of strategies Choice of types of messages

or appeals Targeting Evaluation of intended and

unintended outcomes

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Justifications

Doing good

Doing good

Autonomy Doing good Utility Justice

Ethical Concerns

Identity Doing harm

Doing harm Justice Autonomy Caring

Autonomy Framing Distraction Beliefs Justice Doing harm Consent

Table 6.3

Dilemmas

Privileging

.&&i

Questions Drawn From the Power and Control Dilemmas

Questions

When focusing on specific health problems or particular ways to address them, does the intervention privilege certain stakeholders or ideologies?

Should specific health-related conditions be prioritized over others? Should the perspectives and interests of particular stakeholders

be given priority over those of others? Does the intervention legitimize, prioritize, or privilege particular

agencies or groups compared to others? Are certain social values or ideologies emphasized compared to

others? Do the intervention practitioners have special access to information

or other resources in producing (persuasive) information and getting it disseminated?

Do particular organizations or groups have more access to information to support their claims regarding the intervention's priorities?

Do particular organizations or groups have relatively more resources to access sociodemographic characteristics of target audiences, which would enable them to develop more persuasive messages?

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Exploitation When involving community or other voluntary organizations in the campaigns, which presumably aim to advance values of p.articipation and empowerment, to what extent does this in fact serve to exploit these organizations?

Are particular organizations made to feel obligated to participate in the intervention's activities? What is the basis of this obligation?

Should organizations that choose not to be involved in the intervention be sanctioned?

Are organizations that participate in the intervention exploited by it since diverting their resources toward the intervention's activities might not serve their constituencies or organizational interests in the long run?

Control When providing health-promoting services, to what extent might their use serve to control organizational members?

To what extent does the intervention promote a topic that can serve as a means for social or organizational control?

Design Implications Justifications

Choice of goals Utility Choice of strategies Choice of partners Choice of types of messages

or appeals Choice of evaluation outcomes

2

Choice of strategies Choice of allocation of

resources

Ij'M'!

Choice of goals and level of intervention

Choice of goals Evaluation of unintended

consequences

Autonomy Utility

Utility Doing good

Ethical Concerns

Justice Truth Utility

Justice Framing Autonomy Doing harm

Autonomy Consent Belief

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NOTES

1. Interest in ethical issues in the health care context is increasing, which is evident in the inclusion of ethics in health professionals' training, in the growth of the number of books on bioethics, the creation of ethics committees in hospitals, and in recent editions of health communication books (e.g., Kreps & Thornton, 1992; Thornton & Kreps, 1993; Northouse & Northouse, 1992).

2. See Burdine, McLeroy, and Gottlieb, 1987; Duncan and Cribb, 1996; Eisenberg, 1987; Faden, 1987; Faden and Faden, 1982; Gillon, 1990; Gruning, 1989; Morgan and Lave, 1990; Parrot, Kahl, and Maibach, 1995; Salmon, 1989; Wmett et al., 1989; Witte, 1994.

3. This is previously discussed in Chapter 3, which presents an alternative framework regarding ethical concerns in health communication interventions or campaigns.

4. See an excellent review by Cambridge, McLaughlin, and Rota (1995). Nagel (1983) presents ethical dilemmas in policy evaluation. Some of these share the same concerns raised in this chapter. The nine dilemmas he discusses concern policy optimization, sensitivity analysis, partisanship, unforeseen consequences, equity, efficient research, research sharing, research validity, and handling official wrongdoing.

5. Duncan and Cribb (1996) present on asirnilar critique but offered less of a detailed analytic approach, drawing on the work of Faucault (1975, 1977).

6. See Elder, Hovell, Lasater, Wells, and Carleton, 1985; Evans, 1988; Fine, 1981; Lefebvre and Flora, 1998; Jaccard et al., 1990; Manoff, 1985; Manuel et al., 1991; Rogers and Storey, 1987; Scherer and Juanillo, 1992. For example, the National Cholesterol Education Program's (NCEP) 1992 Communication Sttategy document states that it

is not enough to create messages based on scientific consensus-it is critical to provide messages that the audience will understand, that they will care about, and that they can act on. To accomplish this, the NHLBI's public education efforts have successfully employed the principles of social marketing. (po 8)

7. See also a discussion by Laczniak et al. (1979) on ethical issues in social marketing. 8. Not all health promoters believe these to be the most effective techniques. See Wallack's

(1989) critique. 9. A popular approach is the use of focus groups.

10. The National High Blood Pressure Education Program followed this approach when it used messages intended to arouse fear of stroke in its public service messages based on findings from focus group interviews. Reported in Analysis of High Blood Pressure and Cholesterol Target Audience andMessage Test Reports, 1978-1991, prepared by E. B. Arkin, August 1992, for NHLBI.

11. In this case, though, the planners might have also assumed that fear appeals might be ineffective, according to the authors. The use of fear appeals has been endorsed as effective, for example by the National Heart, Lung and Blood Institute's National High Blood Pressure Education Program in its 1993 communication strategy plans .

12. An additional discussion is presented in Chapter 3 in the discussion of strategies. 13. This was discussed in Chapter 3. 14. For a recent treatment of the ethical issues regarding the use of "sin taxes,» see Kahn

(1994). 15. This is discussed as one of the health promotion paradoxes in Guttman, Kegler, and

McLeroy (1996). 16. For example, bicycle helmet promoters in Quebec found that the benefits of their program

were unequally distributed and that the program was one third as effective in poorer municipalities. This concern further developed in the dilemmas concerning inadvertent outcomes.


17. In fact, it might even cause inadvertent harm, as discussed in the Culpability Dilemmas section

18. This approach is mentioned in most, if not all, the official documents of NCEP and NHBPEP reviewed by the author. It is detailed in NCEP (1990). For an in-depth epidemiological rationale, see Geoffrey Rose (1981, 1985).

19. Kenneth McLeroy presented this paradox in the Society for Public Health Education's Scientific conference in North Carolina in 1994. It is described in Guttman et al. (1996).

20. Nagel (1983), in the context of policy analysis, describes a similar dilemma he calls the Equity Dilemma, which refers to a frequent conflict between policy goals of efficiency and equity.

21. Everett Rogers gave an example, at the 1993 conference of the International Communication Association in Washington, DC, of how practitioners and researchers decided to forego an experimental design of interventions for smoking prevention among children and youth after they got requests to implement their program in communities that were supposed to provide a "control."

22. The Designated Driver campaign typically has not been framed as following a harm reduction approach, but it can be seen as such because its messages essentially condone, or at least do not aim to change, excessive alcohol consumption (by those who are not designated to drive) to prevent alcohol-related auto accidents. An implicit underlying assumption is that because interventions cannot change people's alcohol consumption behavior, at least, health promoters can try to prevent accidents. This approach raises additional concerns regarding the framing of the issue of alcohol consumption to be discussed in the Distractions Dilemma.

23. A third concern is raised in a practice-oriented manual produced by the U.S. Center for Substance Abuse Prevention (1994) regarding the labeling of some young people as at high risk. Even with the intention of furthering their best interests, there may be unintended negative consequences: the label may stigmatize them and may serve as a negative self-fulfilling prophecy. It is suggested instead to refer to "youth in high-risk environments," which emphasizes the critical role environmental factors play in substance abuse.

24. The issue of personal responsibility was discussed in Chapter 2. 25. NHBPEP Communication Strategy (Draft, 1993, p. 24). See "Husband: Darling, did you

take your high blood pressure medicine today? Daughter: Mom, I made Dad's favorite dish for dinner: macaroni and cheese. Mother: Did you remember to use the skim milk and low-fat cheese? Daughter: I sure did." (NHLBI Kit '90, pp. 19-20).

26. We may need to develop ways to determine and make distinctions between formal duties and obligations that may stem from legal relationships, and moral obligations of benevolence or care that stem from special personal ties. This has been discussed in Chapter 3.

27. This was suggested by bioethicist Dan Wikler (personal communication, 1993). 28. As mentioned earlier, NHLBI PSAs presented individuals who did notfollow their medical

regimen, had strokes, and consequently were dependent on others or ruined their retirement plans. This can be seen as falling within the category of people's (irresponsible) behavior being a necessary cause for their condition, as well as the implication that they were not behaving responsibly toward their loved ones.

29. These are found in NHLBI Kit '90. A typical message in this type of campaign is "It's your life, it's your move." This message is from NHBPEP's PSAs. Other types of messages are "You can lower your blood cholesterol: It's up to you. All it takes are some simple diet changes," or "You are in control." These messages imply that one's behavior change is sufficient to influence one's health, which as will be discussed, puts the main burden on the person.

30. This is described in Guttman (1994). 31. For example, in a report ofa focus group in a local heart disease prevention program whose

members were from a from a lower socioeconomic background, the participants described themselves as being "weak" (of character) or having "lack of willpower" to explain why they did not consume only low-fat foods to prevent potential health complications. The report concludes that in general, "these people didn't perceive themselves as mentally tough or competent to put up


with sacrifice, pain, and suffering. Their discussion was peppered with negative self-statements and statements of (low) s~lf-worth" (Guttman, 1994). This observation suggests that they blamed

, ~t emselves for not adopting the recommended health-promoting behaviors and felt guilty about I.

32. There are different theories and interpretations of justice and several perspectives on how cos~s a~~ benefits should be distrib,uted. One perspective emphasizes the notion of giving equal avadab!hty of the health promouon resources to everyone while others allocate resources ac~or.ding to those who are perceived as bearing the greatest need, in an attempt to balance the prInCiple of equity with people's inequalities regarding personal abilities and circumstances (Garret et aI., 1989).

33. The National Ch~lest~rol ~du~tion Program's (1990) report on Population Strategies for Blood Cholesterol R,eductlon CItes findings that foods that are particularly sensitive to income level are meats, fresh frUIt, and vegetables. The latter are seen as important to a nutritious diet. It also ~eports that ~he consu~ption of low-fat milk and whole-grain bread is positively related to Income, pOSSlb~y. reflectIng ~he grow~g' concern regarding health in the higher socioeconomic groups. In addluon, according to thIS report, research findings indicate that the use of fresh vegetables, ,fresh fruits, and juices decreases as household size increases, and intakes of vitamins C an~ B6 are Inversely r~lated to household size, as expected from lower income elasticity for fresh frUIts and vegetables In larger households. Educational levels are also found to influence food consumption, where higher educational level is associated with consumption of fruits and milk and lower consumption of so-called convenience foods, and these families are reported to eat more meals together.

~4 .. D~els (1985) provides a framework ofren cited in the bioethics literature for the analysis of Ju~~ce In the context of h.ealth care. See also Chapter 2. He argues that justice is based on prOVIding access or op~ortun~ty to resources that allow individuals to provide for their necessary needs but no~ necessard! theIr pre~erences. Once individuals have access or opportunities, they can make theIr own chOICes regarding the types of risks they want to take. Some people though may have, special needs that are not merely preferences, and these need to be addressed u: a special way. DanIels alS? :rrgues that for.a p~e."ention activity to meet claims of justice, it needs to provide equal opporturuues to prevent indIVIduals from being exposed to risks. Prevention efforts that pro~i~e opportunities only for people with greater socioeconomic status, such as the promotion of ~U~IhOUS foods that are only available at higher prices, can be seen as not meeting this criterion of Jusuce.

35. Incentives such as competition and prizes have been the cornerstone of several demonstration inte~ventions in Finland and the United States and adopted in local efforts (see Gu~an, 1994). Feingold (1994) reports of "disincentives" posed by Hershey Foods Corporation ~n Its employees: ~ey have to pay an extra $30 a month if they have high blood pressure and $10 If they do not exercIse.

36 .. ~ollay (1989) makes a similar point in his discussion of distractions in the context of advernslng: "P.romotin~ the trivial is criticized as wasteful or indulgent, distracting resources from more substantIal needs (po 187). He suggests, though, that in the case of public information campaigns, "the criticism of triviality is less germane than in the case of product advertising" {~. 18~. The authors cited in this chapter (e.g., Forester, Bellah et al., Barsky) are likely to disagree WIth thIS comment.

37. See Milio (1981) for a detailed discussion. Farrant and Russell (1987) describe in detail how health promotion materials developed in Great Britain for the prevention of heart disease excluded the discussion of how social factors can contribute to this disease. See also Duncan and Crib (1996).

38. See Waitzkin (1989, 1991) for a discussion of the social-political-economic factors of the etiology of illnesses and arguments for why it should be raised in the context of the medical practiti?ner-patie~t encoun~er. !his cri~que has. been aimed also at the campaigns that promote the deSIgnated drIver, a tOPIC dIscussed In the ddemma of harm reduction. They can be seen as

~

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framing the issue of drunk driving as logistical--people need to make sure that the person who is supposed to drive is not intoxicated. The issue is not framed as a cultural and normative issue. Thus, the norms, values, and practices related to alcohol consumption and the economic interests in maintaining current high levels of consumption are not addressed in the campaign.

39. This rather than as a means to another end or as an instrumental value, as explained by

Green and Kreuter (1991). 40. 6ee Tesh (1988). 41. See Fox (1977), lllich (1975), and Zola (1975) for critiques of medicalization. 42. See also Fitzgerald (1994) and Gillick (1984). 43. For example, for discussions on public perception of restrictive policies, see Bull,

Pederson, and Ashley 1994; Casswell, 1994; Forster, McBride, Jeffrey, Schmid, and Pirie, 1991; Gostin and Brandt, 1993; Hilton and Kaskutas, 1991; Jones-Webb, Greenfield, and Graves, 1994;

Schmid et al., 1990.


SOURCE: Collage by Oren Kramek.

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